Should an 80-year-old female with a history of Transient Ischemic Attack (TIA) and current moderate anemia, status post femur fracture surgery, continue or hold her aspirin (acetylsalicylic acid) 81mg daily?

From the Guidelines

For an 80-year-old female with a history of TIA, current moderate anemia, and recent femur fracture surgery, I strongly recommend temporarily holding the aspirin 81mg daily. This decision is based on the need to balance the risk of bleeding, particularly in the context of recent surgery and anemia, against the risk of thrombotic events given her history of TIA. The guidelines for the management of transient ischemic attacks emphasize the importance of antiplatelet therapy in the secondary prevention of stroke and other vascular events 1. However, in the acute setting of surgery and anemia, the risk of bleeding may outweigh the benefits of continued antiplatelet therapy.

Given her current anemia, with a hemoglobin level that dropped to 6.x and gradually improved to 8.2, it is crucial to prioritize measures that minimize the risk of further bleeding complications. Aspirin, even at low doses, inhibits platelet function and could exacerbate bleeding tendencies, which is particularly concerning in the post-surgical period. The recommendation to hold aspirin temporarily is in line with the principle of managing patients with a high risk of bleeding, such as those with recent surgery or active bleeding, where the cessation of antiplatelet therapy may be necessary to prevent or control bleeding.

Once the patient's hemoglobin levels improve and surgical healing is adequately established, typically within 1-2 weeks post-surgery, the aspirin should be restarted to mitigate the risk of cerebrovascular events associated with her history of TIA. The decision to restart aspirin should be made in consultation with both her orthopedic surgeon and neurologist or primary care physician, taking into account the individual's overall clinical condition and the balance between the risks of bleeding and thrombotic events. When restarting, continuing with the same 81mg daily dose, taken with food to minimize gastrointestinal irritation, is advisable. Close monitoring for any neurological symptoms during the temporary discontinuation of aspirin is essential to promptly identify and manage any potential cerebrovascular events.

From the FDA Drug Label

Stomach bleeding warning: This product contains an NSAID, which may cause severe stomach bleeding The chance is higher if you are age 60 or olderHave had stomach ulcers or bleeding problemsTake a blood thinning (Anticogulant) or steroid drugTake other drugs containing prescription or nonprescription NSAIDs (aspirin, ibuprofen, naproxen, or others)have 3 or more alcoholic drinks every day using this product

The patient has a history of TIA and is currently taking aspirin 81mg daily, but she has developed moderate anemia with a hemoglobin level that dropped to 6.x and then gradually increased to 8.2 after recent surgery. Given her current anemia and age (80 years old), the risk of stomach bleeding is higher.

• The patient's anemia may be a sign of bleeding, and continuing aspirin may worsen the condition.
• There is no direct information in the drug label that addresses the management of aspirin in patients with anemia. However, caution is advised when using aspirin in patients with bleeding risks. Considering the patient's age and anemia, it is recommended to hold aspirin temporarily until her anemia is resolved and bleeding risks are reassessed 2.

From the Research

Anemia Management in Perioperative Period

• Anemia is a common condition in the perioperative period and is associated with poor patient outcomes 3, 4.
• The management of anemia in the perioperative period is crucial to prevent complications and improve patient outcomes 5, 6.
• Strategies to prevent and manage anemia include iron supplementation, erythropoiesis-stimulating agents, and patient blood management 3, 4, 6.

Aspirin Therapy in Patients with Anemia

• There is no direct evidence in the provided studies regarding the management of aspirin therapy in patients with anemia and a history of TIA.
• However, it is essential to consider the risk of bleeding and thrombosis in patients with anemia and a history of TIA when making decisions about aspirin therapy.
• The decision to continue or hold aspirin therapy should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.

Considerations for the Patient

• The patient's recent surgery and anemia may increase the risk of bleeding complications if aspirin therapy is continued 7.
• On the other hand, the patient's history of TIA may increase the risk of thrombotic events if aspirin therapy is discontinued.
• Further research is needed to provide evidence-based guidelines for the management of aspirin therapy in patients with anemia and a history of TIA 7, 6.